Eating Disorders in Adolescent Females

1. Eating Disorders in Adolescent Females Kristin M. Rager, MD, MPH Director of Adolescent Medicine, Levine Children’s Hospital

2. Outline • Brief Case • Signs/symptoms of eating disorders • Diagnosis • Medical Complications • Medical Treatment

3. Case PresentationPatient N • 19 year old female, college freshman • Referred to me by her OB/GYN who had been treating her amenorrhea with OCP’s • Has lost 20# since starting college about 4 months ago

4. Before and After Photos

5. Differential Diagnosis • Brain Tumor • Inflammatory Bowel Disease • Hyperthyroidism • Cancer • Depression • Eating Disorder

6. weight loss menstrual period changes fatigue dizziness, fainting abdominal pain or bloating heartburn, chest pain hair loss trouble sleeping Eating DisorderPhysical Symptoms

7. Behavioral Signs • restrictive diet • frequent weigh-ins • unwitnessed meals • uncomfortable eating at social gatherings • excessive exercise • excessive bathroom time • smell of vomit • disappearing food

8. Emotional Symptoms • perfectionist attitude • sadness • irritability • anxiety • complaints of being or feeling fat • comments about feeling worthless

10. History • Weight loss • Eating patterns • Exercise • Medication use • Vomiting • In addition to losing 20#, patient N was eating 400-600 kcal/day, exercising at least an hour a day, and purging if forced to eat a “real meal”. She also states her goal is to lose 15#

11. PE • Cachexia • Delayed pubertal maturation • Bradycardia, Hypotension • Hypothermia • Dry skin/hair • Lanugo • Yellow skin • Acrocyanosis

12. Ideal Body Weight (IBW) • Females • Ht 5’0” = 100 pounds • Each additional inch = 5 pounds • Males • Ht 5’0” = 110 pounds • Each additional inch = 6 pounds • Patient N was 5’4’’, therefore her IBW was 120#. At her initial visit, she weighed 95# (79% of IBW)

13. Eating Disorders Continuum DSM IV Eating Disorders Eating Disorder, NOS Anorexia Nervosa Bulimia Nervosa

14. According to the APA • 9:1 Females to Males • 0.5% of women will be diagnosed with AN • 1-3% of women will be diagnosed with BN • >5% will be diagnosed with EDNOS • May occur in all ethnicities • Onset usually in adolescence

15. Prevalence of Eating Disorders • “At any given time, 10 percent or more of late adolescents and adult women report symptoms of an eating disorder. Although these symptoms may not satisfy full diagnostic criteria, they do often cause distress and impairment. Interventions with these individuals may be helpful and may prevent the development of a more serious disorder” • Academy of Eating Disorders

16. 2005 Charlotte Mecklenburg YRBS“Vomited or took laxatives to lose or keep from gaining weight”

17. The Etiology of Eating DisordersIs Unknown… • However, the causation is multifactorial, with importance of particular factors varying among individuals.

18. Factors Involved Include • Psychological • Interpersonal (Family) • Social/Culture • Biological

19. Psychological Factors • Pre-Existing Mood Disorder • Pre-existing Anxiety Disorder • 50 – 60% Of Persons with AN & BN had a childhood anxiety disorder. • Sexual Abuse/ Adverse Life Events • Higher levels of shyness and loneliness • Low social support • Difficulty in expressing emotion • Low Self-Esteem

20. Interpersonal/Familial Factors • Troubled family or personal relationships • Family focus on weight and appearance • Teasing and/or bullying about weight/size • Teasing/ bullying in general

21. Social Factors • Cultural Emphasis On Thinness • Media • Emphasis On Dieting

22. Genetics Loads The Gun…

23. Environment Pulls The Trigger

24. Anorexia Nervosa

26. Anorexia Nervosa- DSM IV • Refusal to Maintain Body weight at normal for Height/Age (<85% of IBW or BMI <17.5) • Intense fear of gaining weight or becoming fat • Disturbed body image, undue influence of body shape on self-evaluation, denial of seriousness of current low weight • Amenorrhea X 3 months

27. Anorexia per DSM IV • Subtypes: • Binge-Eating/Purging Type: During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior • Restricting Type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior

28. Bulimia Nervosa

29. Bulimia Nervosa – DSM IV • Binge eating • Eating within a 2 hour period an amount of food that is definitely larger than most people would eat • A sense of lack of control over eating during the episode • Recurrent compensatory behavior in order to prevent weight gain • Both occur on average of twice a week for 3 months • Self-evaluation in unduly influenced by body shape and weight

30. Eating Disorder NOS – DSM IV • Someone who doesn’t meet criteria for AN/BN • Binge eating disorder • All criteria for AN but still with menses • All criteria for AN but weight normal • All criteria for BN but lower frequency • Purging but no binge eating • Ruminating

31. Medical Complications • No organ system is spared • Primarily related to weight-control behaviors and malnutrition • Most improve with nutritional rehab

32. Minnesota Starvation StudyDr. Hansel Keys • Conscientious objectors to WWII • 36 Male Philosophical Pacifists • 20-30 year olds with some college • 1 year in football dormitory • Objectives: • to see what happens to physically, mentally, psychologically when starved • To figure out optimal nutritional rehab

33. Minnesota Starvation Study • 3 months normal nutrition • 6 months starvation • Approximating nutrition of central Europe at that time • 3 months nutritional rehab

34. Major Mental Health Changes • Significant depression • “I have never wanted anything to come to an end more. Not because of food per se, but because I didn’t enjoy anything anymore. Everything that made life worthwhile went.” • Irritability, isolation • Frequent outbursts of anger • Weekly MMPI – increased depression and hysteria

35. Neuro/Psych • Ventricular enlargement/cortical atrophy • Cognitive slowing • Suicidality (most common cause of death) • mortality of >5%

36. G.I. • Delayed gastric emptying • Constipation • Reduced peristalsis

37. Cardiovascular • Bradycardia (40% <40, 12% <30) • Orthostatic instability • Decreased LV mass (up to 40% of patients) • Prolonged QTc • Arrhythmia and sudden death

38. Endocrine/Metabolic • Hypothalamic hypogonadism • Decreased FSH, LH, estrogen • No LH surge–no ovulation-amenorrhea • In 2/3, amenorrhea precedes significant weight loss • 85% of patients will have return of menses within 6 months of reaching 90% IBW • Hypometabolic state (REE reduced by up to 50%)

39. Musculoskeletal • Osteopenia • Decreased deposition • Increased resorption • Primarily due to low estrogen • No evidence that this is improved with Estrogen supplementation • Reduced bone age

40. Complications Specific to Purging • Hypokalemic metabolic alkalosis • Enamel erosion • Parotitis • Callouses on dorsum of hand • Esophagitis • Gastritis • Mallory-Weiss tear

41. Labs to Get • TSH • CBC • ESR • BMP w/ Ca, Mg, Phos • UA • Baseline EKG

42. Treatment of Eating Disorders • Weight Restoration Is The Cornerstone Of Treatment For Anorexia Nervosa • Eating Disorders CAN Be Successfully Treated • The Sooner A Client Begins Treatment, The Better The Prognosis • Team approach

43. Eating Disorder Treatment Team Therapist Medical Provider CLIENT Nutritionist Clients’ Family

44. Medical TreatmentFirst Visit • Determine weight and height • Determine baseline caloric intake • Develop meal plan – usually 3 meals/2 snacks • Food journal • Limit exercise • Set initial goal weight (expect ½ to 1#/week gain) • Arrange follow-up with entire team • Decide if needs admit/Level of care

45. Criteria for Hospitalization per SAM/APA/AAP/ADA • ≤75% IBW (APA says <85%) • Dehydration • Electrolyte imbalance • Cardiac dysrhythmia • Arrested growth and development • Failure of outpatient treatment • Acute food refusal

46. Admit criteria • Uncontrolled bingeing/purging • Acute medical complications of malnutrition • Acute psychological emergencies • Severe depression • Suicidal ideation • Comorbid diagnosis that interferes with treatment of eating disorder

47. Admit Criteria • Physiologic instability • HR<50 day/HR<45 night • BP< 80/50 • Temp<96 • Orthostasis (HR>20, BP>10)

48. Levels of Care INPATIENT RESIDENTIAL PARTIAL HOSPTIALIZATION INTENSIVE OUTPATIENT OUTPATIENT

49. Inpatient Hospital Stay • Monitor meals and 1 hour post meal • Gowned weights (to tell or not to tell….) • Daily urine specific gravity pre weight • Daily electrolytes • Increase calories by 200-300 each 1-2 days (start at 20 kcal/kg/day) • Inadequate intake NOT an option • Nutrition consult for meal plan

50. Hospital Stay • Initially will lose weight (1-3 days) • After that, want 100-150 gram/day gain • Initially only out of bed to bathroom • Stretching at 75% IBW • Walking at 80% IBW